Democrats should welcome reform of the reform

By
Ezra Klein

Responding to the moderate Democrats who are proposing alternatives to the individual mandate, Greg Sargent says "all they're succeeding in doing is undermining one of the Democratic Party's signature domestic accomplishments." I disagree. I think they're separating politicians engaged in good-faith discussions about how best to reform the health-care system from those involved in a bad-faith discussion that attempts to claim the mantle of reform while being interested primarily in a return to the status quo. This somewhat dovetails with my column today, which argues:

Replacing the individual mandate wouldn't be particularly hard. All we need is another policy that does the same thing -- specifically, discourages free-riders who don't want to buy insurance until after they get sick and thus leave the rest of us paying for them.

In fact, I can give you four credible alternatives in four sentences:

l We could limit enrollment changes to once every two years, so people who decide to go without insurance can't buy coverage the moment they get a bad report from their doctor.

l We could penalize those who wait to buy coverage with higher premiums, which is what we do in the Medicare Prescription Drug Benefit.

l We could have a five-year lockout, in which people who decide to go without coverage wouldn't be able to access the subsidies or insurance protections for five years, even if they decided they wanted to buy insurance.

l We could raise taxes by the same amount as the individual mandate penalty and give everyone who showed proof of insurance on their tax forms a "personal responsibility tax credit" of the same amount.

The danger, as I say at the end, is not that the law does get changed, but that it doesn't. That the GOP won't let it thrive and the Democrats won't let it die and so it just limps along.

Crucially, however, that's not a popular position, Poll after poll shows reform -- or, if you prefer, some sort of "replace" -- to be more popular than repeal. What the moderate Democrats are doing is making it harder for Republicans to hold the line on straight repeal. You don't usually see Ben Nelson spitting fire, but his messaging on this is exactly right. "What’s their plan?" He asked. "Is their plan, 'hope you don’t get sick?'”

And you're already seeing some cracks in the Republican ranks. Mitch Daniels has a plan to reform the bill. Scott Brown has partnered with Ron Wyden on a waiver allowing states to go their own way. Rep. Sean Duffy said his preference was "reform the reform or repeal and replace," and he almost voted against the GOP's repeal effort. Eventually, Republicans are either going to have to actually bring out a plan of their own -- and that hasn't worked very well for them any of the other times they've tried it -- or they're slowly going to lose ground in this debate, and as we get closer to the next election, more and more Republicans will begin looking for an out.

Democrats should be willing to give it to them. Will they love the policy? Probably not. But policy isn't the only ingredient in the law's success. Buy-in matters, too. If Republicans make peace with the law and become more willing to participate constructively in its implementation and perfection, that's worth a lot in terms of how well it ultimately works. More, I think, than will be given up by doing something like switching the individual mandate out for an open enrollment system.

"he almost voted against the GOP's repeal effort"
What does that mean? It was a party line vote, however much he pretended to hem and haw to appear deeply serious. It's like someone claiming they're mostly a virgin- either he voted for it or he didn't.

scarlota is correct. They aren't ever going to deal in good faith, they'll just try to keep chipping away until they get repeal. In the meantime, there's absolutely no chance that they'll actually produce that "replace" plan. And if they do, we all know that it will suck.

Also, thanks for positioning this as a fight between the current mediocre bill and much worse ideas. Glad to see you're not trying to make it better. Here's an idea that's simple, popular, and clearly Constitutional: Medicare for everyone.

But then, the Washington Post hates Medicare, so I'm not too surprised you won't fight for it either.

Face it, Ezra, it was bad legislation that no one understood (per Pelosi) that has gotten more foul the more we learn about it. We need to start all over! The progressive left cheated and bribed their way into the bill (via Stupak..the traitor). Let's get past this mess with a real bill!

I find it amusing how the tone of Ezra's blog has changed on the health care legislation. Last year at this time Ezra was a leading cheerleader, encouraging his Democratic team to ignore the elections in Massachusetts, Virginia, and New Jersey and ram the "Historic" legislation down the throats of the American taxpayers. Now, after the shellacking at the polls, Ezra is much more tempered, agreeing with the majority of Americans that the legislation is in need of major reform or replacement.

The problem with all of your substitutes is that they don't solve the fundemental problem that the individual mandate does, namely make sure that a person has a way to pay for their health care when they get sick. All you are doing is relegating people who choose not buy insurance to the state they are in today; either they go without healthcare and die (which is a healthcare failure) or get their healthcare in a not-optimal way, costing the rest of us too much money.

We could limit enrollment changes to once every two years, so people who decide to go without insurance can't buy coverage the moment they get a bad report from their doctor.

Would you as a liberal in good standing really tell a single mother of 4 that because she didn't enroll she can't get coverage for two years?

"We could have a five-year lockout, in which people who decide to go without coverage wouldn't be able to access the subsidies or insurance protections for five years, even if they decided they wanted to buy insurance."

Did you also suggest going back to pre-ex for a period of up to 5 years for those that don't enroll? Would that include those from Mass?

I'm w Ezra on this. States want to go their own way? Fine. Are we scared of that for some reason? Maybe some states will hit upon solutions that are better and are more widely adopted.

And as to the Republicans continuing to drive toward full repeal, there is no need to win them over. It's only necessary to break their ranks. If some hard red state wants to try something more "conservative" (whatever that means), maybe they'll be right.

Oh and congratulations on winning some seats in 2010. Dems won in 2008 and passed HCR. I hope you do something useful with your "mandate" because anything other than productive action is small minded and unpatriotic.

Wow, there's a lot of stupidity going on in here. Last year Ezra thought it was a good bill and should be passed. This year's Ezra still agrees. At no point did anyone, anywhere think this was a perfect bill that would never need to be modified, ever. That there are things that can improve it does not mean it wasn't worth passin in the first place.

Also, Ezra's right that eventually Republicans will "make peace" with the legislation, assuming it survives in some form through the Supreme Court, which seems likely. Maybe the bill will lose the individual mandate, but as countless posts have shown, that will make the bill worse, but not completely undermined, and it's something that can be replaced. Unless the Republicans get the White House and both houses of Congress in 2012, they're going to run out of enthusiasm for repeal long before they have the votes to do anything about it. For better or worse (worse), it's very hard to get the government to do things in this country, and at this point repealing the ACA is "doing something". Getting the Republicans to hurry through this go-nowhere repeal phase to a point where they can start advocating for reforms will be good if we can do it.

--*All we need is another policy that does the same thing -- specifically, discourages free-riders who don't want to buy insurance until after they get sick and thus leave the rest of us paying for them.*--

I must have missed it: How many people are there who don't have health insurance, but do have enough money to purchase health insurance, yet will refuse to pay their health care bills that accrue? It *is* possible to set up payment plans with hospitals, after the fact.

Seems to me that there are people who don't have health insurance because they can't afford it, and DeathCare isn't going to turn them into non-free riders. They will always be free riders.

And there are those who don't have health insurance yet can afford it but choose not to buy it because they feel they won't need it.

And then there are those without insurance who feel they can afford to pay for any care they need, alá Rush Limbaugh. It's a relatively small group.

Is the middle group large enough to make Klein's pronouncement sensible, or do most people who can afford insurance in this day and age go and buy insurance?

“But policy isn't the only ingredient in the law's success. Buy-in matters, too.”

Again, the law PASSED. Do we have the rule of law in this country? The law will be implemented eventually and then try-and-see will crush Republican propaganda and opposition. But if you greatly weaken the laws effectiveness Ezra, then it will be a lot less popular, and these opt-out ideas COULD greatly weaken it:

1) Very large numbers of poor people (and middle class) may opt out nonetheless. There could be far more uninsured. Poorer people may not even agree to pay $200/year for health insurance. They may say they can’t afford it. But because of positional/context/prestige externalities effects, make it mandatory, and then all their peers just basically do it, spending less on cars, clothes, eating out, rent, driving rents down, etc., and suddenly it’s affordable (plus there’s a lot more pressure for government to keep up the subsidies). For more on this see:

3) Premiums may be much higher because of healthy people opting out nonetheless, and then doing the five year wait before opting in once their health gets worse, once they get high blood pressure, rheumatoid arthritis, obesity, adult onset diabetes, etc. The insurance companies may be ok with this because it’s not enough to cause a complete death spiral, but families still pay a lot more.

4) Economies of scale and simplicity are lower.

5) As a result of the above the program is a lot less effective and so a lot less popular.

6) Once you get rid of the individual mandate it’s like admitting that the Republicans were right. It’s a terrible affront to freedom and unconstitutional. It will be far harder to add it later when we see the bill now is much worse and falls far short of universal coverage.

"If Republicans make peace with the law and become more willing to participate constructively in its implementation and perfection, that's worth a lot in terms of how well it ultimately works."

THIS Republican Party??!!

I can't see them (the billionaires that pull the strings, not just a few split-off congresspeople in swing areas with no party power) ever not calling Obamacare the death of freedom and the economy, no matter how you modify it.

The only thing that will stop their virulent opposition is what stopped their virulent opposition to the New Deal, Medicare, etc. -- try-and-see creating unopposable public support.

If democrats agree to implement reforms to the health care bill, what are they getting in return?

At the end of the day, liberals are on the right side of this issue. Polling shows people would rather have the law expanded than repealed, people morally agree with universal health care and most importantly, the bill has already been passed.

If Democrats agree to waive the individual mandate they should insist on bring back the Public Option.

After all, if Republicans really want to increase consumer choice, who are they to deny me the right to choose the Public Option?

The idea is to have as many Americans as possible covered by some form of health insurance. Any form of "opt out" immediately defeats the purpose and basically puts us right back where we are now. Ideally this form of health insurance should be a single payer, government provided system but since so many people have been brainwashed to believe that this is evil we may have to wait a few more election cycles before it actually happens.

Fool me once, shame on you. Fool me twice, shame on me. Ezra, every time the Democrats have modified health care reform to get Republican support, they've had the rug pulled out from under them by the Republicans, who oppose it anyway. Why would this time be any different?

"All we need is another policy that does the same thing -- specifically, discourages free-riders who don't want to buy insurance until after they get sick and thus leave the rest of us paying for them."

WELL DUH!! YOU LIBS CREATED THIS MESS!!

You forced the medical system to treat everyone, regardless of ability to pay. You changed medical insurance into a buyer's club. You forced the insurance companies to take everyone with pre-existing conditions.

Insurance is for unforeseen circumstances. Maintenance is for pre-existing conditions. Shouldn't fat people pay more for insurance?? But you won't let insurance companies charge them.

You think this O-bomination was negotiated in good faith. Nice try, if it was it would not be 2700 pages of give aways to the cronies who got our legislative and administrative neophyte elected. If it was in good faith the damn republicans would have been included in the drafting of a true reform bill rather than turning it over to the uber-socialists who ran the senate and the house. If it was in good faith we would not have had to pass the bill to know what was in it. If it was in faith it would not have taken a legislative legerdemain to pass it. If it was in good faith it would not be 10 years of funding for six years of coverage. If it was in good faith the people would have been listened to at the town hall meetings in the summer of 2009. If it was in good faith there wouldn't be the need to waste further time on having to amend such a monstrous bill. You wasted nearly two years shoving this down the American people's throats while the economy sunk further into the morass and now, rather than addressing the Obamacare nightmare you want to act concerned about the economy! The people aren't as dumb as you would like to believe they are and certainly are not in need of further dependency that you would foist upon us.

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